Here’s why you should keep your physicians’ work schedules on file.
Correctly billing your nonphysician practitioners (NPPs) incident-to services means the difference between 85 and 100 percent reimbursement. But if you bill incident-to haphazardly, you’re just waving a red flag at auditors.
And those auditors are jonesin’ to find incident to billing problems. Just check out this recent report from the HHS Office of Inspector General to learn the kinds of mistakes they’re looking for.
But have no fear. If you use the following list of questions to evaluate your incident-to claims for all the must-have components, and be sure the documentation includes the same, you’ll have nothing to worry about if auditors come knocking.
1. Do the Services Involve Direct Supervision?
Direct means that the supervising physician must be in the immediate office suite while incident-to services are being provided. But if you’re too conservative with the word direct, you could be giving up the extra reimbursement that comes with billing incident to. Direct doesnt mean that the physician has to be supervising the work elbow-to-elbow with the NPP.
Example: A physician has treated Patient A for psoriasis and reported 96921 (Laser treatment for inflammatory skin disease [psoriasis]; total area 250 sq cm to 500 sq cm). Patient A returns for a follow-up appointment with a nurse practitioner (NP). The supervising physician is in another room evaluating a new Patient B while the NP performs history, exam and medical decision-making relative to Patient As progress. You can bill the NPs service (99212-99215) incident-to the physician for 100 percent reimbursement even though the physician is not present in the room.
Caution: You don’t want to get caught using the term direct too loosely. Having the physician available by phone or somewhere on the grounds in a large facility isn’t acceptable. And you may want to check your state practice act to see if it mandates stricter supervision requirements than Medicare.
Also, don’t confuse other third-party payers incident-to regulations with Medicare’s. Some third-party payers definition of incident to is more lenient. They may follow state supervisory rules, which for some states merely require the physician to be available by phone.
You should also find out from your private payers whether they credential the NPPs. If they don’t credential them, you should get in writing exactly how the payer wants you to bill their services.
Good idea: Keep physicians work schedules on file to prove they were present when incident-to services occurred. In addition, some carriers, particularly HGSA (now known as Highmark Medicare Services), like to see the name of the supervising physician in the actual progress notes, especially if it is a different physician from the one who wrote the care plan.
2. Does the Patient Have an Established Plan of Care?
Incident-to services must be part of the physicians normal course of treatment during which the physician personally performed an initial service and remains actively involved in the patient’s treatment. This means that incident-to billing works only with an established patient following a plan of care for an established problem.
Example: A physician assistant (PA) at a practice sees an established patient who is being treated for a urinary tract infection. The doctor has seen this patient in the recent past and has established the diagnosis and initiated a care plan. The PA performs a follow-up history and examination and continues the prescribed treatment. You can bill an established patient office visit with 99212 (Office or other outpatient visit for the evaluation and management of an established patient …) or 99213 under the doctors name and provider number. Then, reimbursement allowance will be at 100 percent of the physicians global fee.
As long as the patient is not new or undergoing status change and the doctor is in the office suite, the PA can provide the service, and the office can use the doctors provider number when filing the claim with Medicare.
Remember: The supervising physician can be different from the one who actually wrote the plan of care.
Important: The reimbursement must go to the physician who supervised the incident-to services that day.
Beware: An established patient with a plan of care who comes in for a new, unrelated condition is not an appropriate case to bill incident to.
Another option: An NPP, NP, PA, clinical nurse specialist (CNS) or a certified nurse midwife (CNM) can still see an established patient with a new problem for 85 percent reimbursement. But you must bill the services under the mid-level providers own Medicare number, not the physicians.
3. Was the Service Performed in a Non-Hospital Facility by an Employee of the Physician?
A major key to incident-to billing is that it doesn’t apply to a hospital setting. CMS says incident-to services are commonly furnished in physicians offices or clinics.
The only time a hospital setting warrants incident-to billing is when the physician’s office is confined to a separately identifiable part of the facility and cannot be construed to extend throughout the entire facility. For instance, a privately practicing doctor rents a small wing of a large hospital to practice.
In addition, any NPP providing incident-to services must represent a direct financial expense to the physician, CMS says. This means that the NPP must be an employee or independent contractor of the physician’s practice.
Warning: There are 3 more things you must check when billing incident to. Stay tuned to next week’s Coder’s Cranium for more NPP billing essentials.
From Part B Coder’s Rule Book. Available online at www.supercoder.com.
AUDIO: What many practices don’t know about flu shots, EKGs, Laboratory tests, and X-rays as “incident-to” services. And much more from Steve Verno.
Related articles:
- Nonphysician Providers & Incident To ChecklistCheck state laws PLUS this crucial document. In last week’s…
- Steer Your Incident-To Coding Using These 4 Questions 100 percent pay possible if NPP follows internist’s care…
- Use This Incident-To Checklist to Breathe Easy During an Audit You don’t need to second-guess the way you bill…
